Complications related to unsafe abortions represent 13% of all pregnancy-related mortality, and in some countries as much as 25% of maternal deaths [1,2]. About 55 million unintended pregnancies occur each year to women not using a contraceptive method in developing countries. Another 25 million occur as a consequence of incorrect or inconsistent use of a contraceptive method and method failure [3,4]. In Ghana 16% of births are unwanted, 40% are unplanned and 24% mistimed [5]. Abortions constitute 16% of deliveries and form 11% of maternal deaths [6]. It is estimated that maternal deaths would decline by an estimated 25-35% if contraception were accessible and used consistently and correctly by women wanting to avoid pregnancy [7].

Post Abortion Care (PAC) was identified as an important strategy by the international health community in 1994. This sought to reduce maternal mortality and morbidity by treating complications related to unsafe abortion and miscarriage and provides post-abortion family planning counseling and services to prevent repeat unplanned pregnancies and abortions. However, PAC services have over the years aimed mainly at reducing maternal mortality by treating the symptoms of hemorrhage and sepsis rather than addressing women’s unmet need for family planning and contraceptives [8,9]. Because many women resume sexual activity shortly after an uncomplicated abortion and fertility may return as early as 10 days after a first-trimester abortion [10], it is crucial that women who are not seeking another pregnancy are offered effective methods of contraception that they can use immediately after the abortion episode. Pre-and post-abortion counseling on use of contraception have been regarded as appropriate vehicles to decrease unwanted pregnancies and subsequent induced abortions [11-13].

Post-abortion care as a concept was introduced in the country in 2003 [14]. This was followed in 2006 by Safe Abortion Services as permitted by law. Since then, maternal mortality ascribed to abortions has decreased from 22-30% to 11% [6]. This indicates much improvement in managing the acute emergencies associated with abortion, namely hemorrhage and sepsis. Contraceptive uptake has however, not seen a parallel increase as contraceptive prevalence rate (CPR) has remained about the same, 25% to 24%, over same period although knowledge about contraception is almost 100% [5]. Integration of contraceptive services as part of post abortion care has been found not to be adequate [15]. It is believed that a lot of young women undergo induced abortion for unwanted and mistimed pregnancies because of non-use of effective contraception [5,6]. The immediate post-abortion period offers a great opportunity to offer contraceptives to women. Several studies have attested to this fact [11- 13]. The current study looked at the contraceptive preferences of clients who underwent an abortion episode at Komfo Anokye Teaching Hospital, Kumasi, and a tertiary referral centre. It also looked at the rates of acceptance following counseling.

This prospective study used data collected between January and December 2010. Patients admitted to the gynaecologic wards of the hospital for all types of abortions or miscarriages, except Threatened Abortion, were included in the study after obtaining consent. All had uterine evacuation done with the manual/electric vacuum aspirator as primary method of treatment, or following abortion induced/ augmented with oxytocin or misoprostol. They had both pre- and post-evacuation counseling on contraception. Basic demographic data as well as information on previous pregnancy outcomes and past as well as current contraceptive use were obtained and entered onto data collection forms. Data were later transferred onto Epi-Info ver. 3.5.3.

There were 4172 admissions to the gynaecology wards over the period, of which 56.4% were abortions. Of this number, 2243 were entered into the study. The age range was 13-51, with a mean of 27.3 years (SD 6.9). Majority of abortions (68%) were incomplete while 9% were induced, as shown in Table 1. Slightly more women were single (50.4%) than married (49.6%). Eleven percent was unemployed, 18.2% were students, 16.6% were apprentices, while the rest were in employment. Eighteen percent had no formal education, 28% and 43% had been through Junior High and Senior High Schools respectively, while 11% had tertiary education. Mean parity was 1.6 children. While 51% had at least an episode of a previous spontaneous abortion, 42% had at least a termination of pregnancy (mean-1.9). Of the index pregnancy that aborted, 53% were unwanted, 12% mistimed while the rest were desired. While knowledge on contraception was 96%, ever use and current use were 36% and 16% respectively. Following counseling, 68% accepted a form of contraception. Accepting contraception was found independent of marital status (p=0.33), age (p=0.27) and formal education (p=0.31). The combined Pill was mostly favored by 25%. Bilateral tubal ligation was not chosen at all. Table 2 shows type of contraceptive accepted. While 19.5% declined contraception because they wanted a child, 12% were undecided. More than half of those who were undecided were between ages 21-40 years, while 63% were not married. Abstinence was preferred mostly by clients below 20 years and not chosen at all by clients above 40 years. Women above 40 years least accepted contraceptives while those between 21-30 years mostly accepted contraceptives. Table 3 shows types of contraceptive accepted stratified by age.

Table 1: Types of abortion as admitted.

Table 2: Types of contraceptive accepted.

Table 3: Contraceptive chosen against age group.

Although knowledge on contraception was high in the study, only 16% were using a form of contraception before the index pregnancy. Less than one-third had ever used any form of contraception indicating a high unmet need for contraception. This mirrors the national current use rate of 24%. Following counseling 68% accepted contraceptives. Counseling as an integrated part of abortion care has been found to increase contraceptive acceptance in several studies [16-18]. Accepting contraception was found independent of marital status, age and formal education. This is similar to the findings of a national survey [6]. The combined Pill was the most favored (25%) followed by the Injectable Depo-Provera. While this is similar to findings in some studies [16], other studies indicate the injectable being preferred to the combined Pill [17]. Similarly, statistics from the hospital’s Family Planning Centre [18] indicate the injectable as the most preferred method by clients (41%). Preference for the Combined Pill from the Family Planning Centre (24%) is similar to what was found in the study. The IUD was least chosen. Implants were chosen by women across all age groups. Women above 40 years preferred the IUD and Implants, both long-term reversible methods. They were however, not ready for a permanent form of contraception. Over two-thirds of women who chose abstinence were below age 20. Abstinence is the first of the pillars in the fight against HIV infection and this finding on one hand is good news for the country. On the other hand, since most of these women were still in school, the fear of being seen by their teachers and colleagues with contraceptives, especially those in boarding institutions, might have informed their decision to opt for abstinence. The problem here is that these young women are not matured enough to negotiate safe sex especially if their partners are older, and this will still expose them to unwanted pregnancies and sexually transmitted infections. Understandably, tubal ligation was not chosen at all as a method of contraception. Some reasons have been ascribed to clients who refuse contraception [5,19,20]. These include religious beliefs, myths, misconceptions and fears of complications/undesirable side effects. The women who refused to choose a method in the study after counseling, apart from those who wanted a child, mentioned side effects as the most reason followed by myths and misconceptions surrounding contraceptive use.

Whether clients would adhere to these chosen methods for any appreciable length of time, in order to prevent unwanted and mistimed pregnancies was not answered in the study. In one study in Iceland that compared women who had had pre-abortion counseling on contraceptives to those who had not, no statistical difference was found in their contraceptive use after 4-6 months [21]. Another study in Turkey found a significant increase in contraceptive use following counseling after an abortion episode [22].

I appreciate the part played by Ms Juliana Ofori of the Reproductive Health Counseling office for assisting in data entry.